Summary

This report summarizes published findings of a community-based organization in New York City that evaluated and demonstrated the efficacy of the Many Men, Many Voices (3MV) human immunodeficiency virus (HIV)/sexually transmitted disease (STD) prevention intervention in reducing sexual risk behaviors and increasing protective behaviors among black men who have sex with men (MSM). The intervention addressed social determinants of health (e.g., stigma, discrimination, and homophobia) that can influence the health and well-being of black MSM at high risk for HIV infection. This report also highlights efforts by CDC to disseminate this evidence-based behavioral intervention throughout the United States. CDC's Office of Minority Health and Health Equity selected the intervention analysis and discussion to provide an example of a program that might be effective for reducing HIV infection- and STD-related disparities in the United States.

3MV uses small group education and interaction to increase knowledge and change attitudes and behaviors related to HIV/STD risk among black MSM. Since its dissemination by CDC in 2004, 3MV has been used in many settings, including health department- and community-based organization programs. The 3MV intervention is an important component of a comprehensive HIV and STD prevention portfolio for at-risk black MSM. As CDC continues to support HIV prevention programming consistent with the National HIV/AIDS Strategy and its high-impact HIV prevention approach, 3MV will remain an important tool for addressing the needs of black MSM at high risk for HIV infection and other STDs.

Introduction

Major advances in the prevention and treatment of human immunodeficiency virus (HIV) and care for HIV-infected persons have occurred during the past 3 decades. One important advance is development of efficacious behavioral interventions that reduce HIV-related sex and drug-injection risk behaviors and incident sexually transmitted diseases (STDs) among at-risk populations.1 Biomedical advances, such as antiretroviral therapy, afford persons living with HIV long and productive lives and effectively prevent transmission to uninfected persons.2-5 Despite these prevention efforts, approximately 1.2 million adolescents and adults live with HIV, and 41,800-62,900 persons acquire new HIV infections each year in the United States.6,7

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Disparities in HIV/STD prevention and care persist among racial/ethnic minority populations and sexual minorities. Among blacks, the prevalence of HIV is greater than that among all other racial/ethnic groups.8 Despite representing only 12.6% of the U.S. population in 2010,9 blacks accounted for 45% of all new HIV infections that year.8 Black men have a higher proportion of HIV infections at all stages of disease -- from new infections to deaths -- than men of other racial/ethnic groups.8 HIV is consistently among the 10 leading causes of death for black men aged 15-64 years.10

Gay, bisexual, and other men who have sex with men (MSM), and black MSM in particular, consistently represent the largest proportion of HIV-infected persons in the United States.11 Although MSM represent approximately 2% of the U.S. population,12 they accounted for 63% of all new HIV infections in 2010, and black MSM accounted for a larger proportion of new HIV diagnoses than did white or Latino MSM.8 Each year during 2006-2009, HIV incidence increased an estimated 12.2% among black MSM aged 13-29 years, whereas incidence remain stable among white and Latino MSM.7 More new HIV infections occurred among black MSM aged 13-29 years (6,500 diagnoses in 2009) than among white MSM aged 13-29 and 30-39 years combined (6,400 diagnoses in 2009) (7). Black MSM also have higher rates of STDs, including primary and secondary syphilis13,14 and chlamydia,15 than do their white and Latino counterparts.

Higher rates of HIV and other STDs for black MSM than for other MSM are well documented,16 and research has identified several explanations for the excess risk.17,18 These include higher background prevalence of HIV in the community that can lead to exposure to an infected partner despite less risky behavior; higher prevalence of other STDs in the community that can facilitate HIV infection; partnerships with men of unknown HIV serostatus; infrequent HIV testing and later diagnosis of HIV infection; limited access to antiretroviral therapy; stigma, homophobia, and social discrimination; and financial hardship.19-24

However, black MSM reported fewer sex and drug-risk behaviors than did white MSM, and behaviors such as commercial sex work and sex with known HIV-positive persons did not significantly differentiate these groups.17 A cross-sectional study conducted in 2005 and 2006 reported that young black and Latino MSM with older partners engaged in higher rates of sexual risk behaviors and had a greater likelihood of unrecognized HIV infection than did those with younger partners, possibly because of increased prevalence of HIV infection among older partners.25 Many black MSM struggle with negative perceptions of themselves because of internalized racism; marginalization; and feelings of isolation from their communities, families, and religious organizations.26

A combination of social, cultural, and personal factors probably prevents black MSM from accessing health-care services.27,28 Thus, HIV/STD prevention programs for black MSM must target sociocultural determinants of health, in addition to behavioral risk reduction, to successfully reduce disparities and improve health equity.29 However, when the Many Men, Many Voices (3MV) intervention began in 1997, no efficacious, culturally appropriate HIV/STD risk-reduction interventions had been developed for black MSM since acquired immune deficiency syndrome (AIDS) was first recognized in the 1980s.30

Background

Two community-based organizations (CBOs), in collaboration with an STD/HIV prevention training center, created 3MV in 1997.31 3MV has been delivered by various CBOs serving black MSM since its development. Because of an urgent need for risk-reduction interventions for black MSM, CDC has nationally disseminated 3MV since 2004. However, the efficacy of 3MV had never been rigorously evaluated in a randomized controlled trial.

To learn from and assess community-based HIV prevention practice, CDC initiated the Innovative Interventions Project.32 The project aimed to identify and rigorously evaluate culturally appropriate HIV prevention interventions that CBOs were delivering to minority populations at high risk for HIV infection in their communities and that showed the possibility of being effective in reducing risk behaviors. In 2004, the Innovative Interventions Project supported People of Color in Crisis, Inc., a CBO located in Brooklyn, New York, to evaluate the efficacy of the 3MV HIV/STD prevention intervention in a randomized controlled trial.31

This report summarizes published findings from a CBO in New York City to evaluate and demonstrate the efficacy of 3MV in reducing sexual risk behaviors among black MSM.31 In addition to addressing individual-level risk behaviors, 3MV addresses social determinants that can potentially influence HIV-related outcomes among black MSM at very high risk for HIV infection. For example, the intervention positively influences the identity and value of being a "black gay man," thereby reducing the effects of stigma, racism, homophobia, and discrimination that can influence risk behavior. This report also describes efforts by CDC to disseminate the evidence-based 3MV behavioral intervention throughout the United States.

CDC's Office of Minority Health and Health Equity selected the intervention analysis and discussion that follows to provide an example of a program that might be effective in reducing HIV-related disparities between black MSM and other persons in the United States. Criteria for selecting this program are described in the Background and Rationale for this supplement.33

Intervention

3MV is a seven-session, small-group intervention for black MSM that aims to reduce the behavioral risks for acquiring HIV and other STDs and increase health protective actions.34 The intervention focuses on helping black MSM better understand the social, cultural, and behavioral determinants that affect their HIV/STD risk. Moreover, 3MV focuses on perceptions of personal susceptibility to HIV and other STDs; knowledge of STDs and the interrelation between STDs and HIV; awareness of risk-reduction and health-promotion behaviors; skills and self-efficacy related to consistent condom use, condom negotiation, and partner communication; and decisions about testing for HIV/STDs.

Two trained peers co-facilitate the intervention sessions and serve as role models to support risk-reduction efforts. The intervention can be delivered as seven weekly sessions or as a 3-day weekend retreat.34 Behavior change theories and models guiding the development of the intervention include social cognitive theory,35 the behavioral skills acquisition model,36 the transtheoretical model of behavior change,37 and the decisional balance model.38 The intervention sessions involve group discussions, games, and other activities to convey factual information; role play to enhance skill building; and development of personal risk-reduction plans (Table 1).

The personal risk-reduction plan is an innovative component of the intervention that uses menus of behavior change options for HIV/STD risk reduction rather than a singular emphasis on consistent condom use that is common in other prevention interventions for MSM. Black MSM also benefit from participation in the intervention by forming collegial relationships with other black MSM to support the maintenance of their risk-reduction efforts.

Most persons who are trained to deliver 3MV are college educated, although no minimum education is required.34 Facilitators participate in 32 hours of training and skills building during 4 consecutive days. Before they can deliver 3MV, facilitators are trained to know about HIV/STD and about issues such as racism, homophobia, stigma, and discrimination that can affect black MSM. Once trained, facilitators are supervised by program managers of implementing service-provider organizations to ensure fidelity of their delivery to the intervention curriculum.34

Evaluation Methods

During August 2005-November 2006, People of Color in Crisis, Inc., and its university research partners evaluated the efficacy of 3MV among black MSM in New York City using a randomized controlled trial design.31 The study sample comprised 338 black MSM of negative or unknown HIV serostatus. Participants were randomly assigned to the 3MV intervention condition (164 men) or to a wait-list control condition (174 men). The intervention was delivered as a 3-day weekend retreat at a resort in upstate New York. Participants who were randomized to the control condition were scheduled to receive 3MV after completing the 6-month follow-up assessment. The Human Subjects Research Review Committee at Binghamton University, State University of New York approved the study protocol.

Participants' knowledge, attitudes, and behaviors were assessed by using audio computer-assisted self-interview at baseline and at 3- and 6-months postintervention follow-ups. Behavioral outcomes assessed were number of episodes of unprotected (without a condom) insertive and receptive anal intercourse with main and casual male partners; number of male sex partners; number of episodes of condom-protected anal intercourse acts (analyzed as always protected [100%], sometimes protected [1-99%] versus never protected [0%]); and self-reported testing for HIV and other STDs, including gonorrhea, syphilis, and chlamydia.

Retention of study participants exceeded 70% in both study conditions at all follow-up assessments. Outcome analyses used an intent-to-treat approach in which participants were included in the analysis as originally assigned, and generalized estimating equation models were used to assess intervention efficacy across the entire study period. Details about participant eligibility criteria, screening procedures, study implementation methods, data collection, and statistical analyses are reported elsewhere.31

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